Treatment of Crohn’s Disease and Colitis

Can Patients with Inflammatory Bowel Disease (IBD) Have Children?

Yes, the patients with inflammatory bowel disease (IBD) can have babies. However, patients with IBD who plan to give birth to a baby should decide to conceive in the inactive period of the disease. Although it is known that fertility decrease in active period of the disease, it is possible to conceive. However, the unplanned pregnancy in such patients should be supervised by a physician.

The disease may transform into inactive state in response to medications used by patients with inflammatory bowel disease. On the other hand, these medications may have hazardous side effects on an unplanned pregnancy. Therefore, the patients who wish to become pregnant while on treatment of IBD or others with unplanned pregnancy should strictly follow advices and instructions of their doctors.

How Much Does Inflammatory Bowel Disease Affect Fertility?

Women with ulcerative colitis are usually as fertile as healthy women. The answer to questions regarding fertility for patients with Crohn’s disease is not as clear. Since total colectomy and ileo-anal pouch surgery are performed which imply total removal of colon and anastomosis of small intestine to anal canal in the form of a pouch, respectively, for treatment of ulcerative colitis, this major operation may cause decrease in fertility, but it is a temporary or reversible condition.

The fertility recovers within weeks or months. On the other hand, fertility often decreases in active phase of Crohn’s disease and following major surgeries. Excessive and rapid weight loss, which can be seen in active phase of both conditions, may cause amenorrhea (absence of menstruation).

Patients are recommended to postpone pregnancy until optimal conditions are met, when the disease follows a very severe course; necessary time is allowed for surgical scars to heal and for cessation of active phase. It should also be remembered that decreased fertility in patients with IBD is not always caused by the disease and therefore, other potential etiologies should be investigated.

How Does Inflammatory Bowel Disease Affect Fetal Health in Pregnancy?

It is demonstrated that approximately 85% of women with IBD face no abnormality in pregnancy. Congenital anomalies are seen in approximately 1% of babies of women with Crohn’s disease or ulcerative colitis.

Usually, the risk of miscarriage does not increase. These rates are similar to rates reported for healthy women. In fact, problems or complications which are related to pregnancy or affect fetal health are valid for approximately 15% of cases.

However, rate of abortion, premature birth and other gestational complications increases drastically, if a woman conceives in exacerbated phase of the disease. Active phase of the disease should be treated, if possible, before the conception. For example, if it is known that surgery will be needed in near future, it should be performed before the patient gets pregnant.

Do People with Inflammatory Bowel Disease Need To Have Tests Before Pregnancy?

Detailed discussions of medical history, existing overall health and potential nutritional deficiencies with the physician who will supervise the pregnancy as well as laboratory tests that will determine the activity of disease are strongly advised for patients with inflammatory bowel disease before a planned conception.

Evaluation of abdomen and bowel with ultrasound by an experienced doctor can also provide valuable information. Some patients may need further tests and examinations, including endoscopy and radiology studies, at a more comprehensive facility.

Since folic acid supplementation in first several months of pregnancy is beneficial for baby, it can be recommended for all women with or without IBD. However, sulfasalazine or sulfapyridine will likely reduce intake and metabolism of folic acid.

Can Patients With History of Surgical Treatment for Inflammatory Bowel Disease Get Pregnant?

Surgical management of inflammatory bowel disease does not usually affect the course of pregnancy. Even after major bowel surgery such as colectomy (removal of colon) or ileostomy, pregnancy can be completed without complication.

However, the important point is to allow sufficient time for wound healing between the operation and the conception and to ensure that there is no significant disease activity. It is generally advised to wait for a year before pregnancy following major abdominal surgeries. Rarely, ileostomy related complications (e.g. obstruction, prolapse, bleeding) are likely in pregnancy.

Certain cases may necessitate surgery during pregnancy, although it is very rare and the risk of premature birth or miscarriage is very low in patients who are operated on. On the other hand, there are documented pregnancies without any complication in patients with ulcerative colitis who are undergone major surgeries, including total colectomy (total removal of colon), due to lack of response to medication treatment.

How Does Pregnancy Affect Course of Inflammatory Bowel Disease?

Mostly, pregnancy does not affect the activity of IBD or maintenance of remission. However, IBD may recover dramatically or on the contrary, symptoms aggravate in some cases. If the disease is in active form at the beginning of pregnancy, the active form of the disease persists almost throughout the pregnancy in one third of the patients.

Exacerbation of disease is more common in the first trimester and in puerperium. In both Crohn's disease and ulcerative colitis, the risk of exacerbation during pregnancy is similar to the rate of activation in non-pregnant patients with IBD in the ordinary course of the disease.

Episodes of disease in pregnancy usually respond to treatment well. Medications can help reduction of activity and the resultant remission phase can be maintained throughout the rest of pregnancy. Moreover, it should be noted that exacerbated symptoms of inflammatory bowel disease in pregnancy does not imply similar exacerbation episodes in future pregnancies.

Both Crohn’s disease and ulcerative colitis can show the initial symptoms during pregnancy. Generally, course of inflammatory bowel diseases in these patients are not more serious than patients who are not pregnant; however, complaints and need for medications cause concerns in pregnant woman and her family. Pregnant woman and her relatives should be informed in detail about this issue.

May Drugs Used for Treatment of Inflammatory Bowel Disease in Pregnancy Harm the Baby?

Every pregnant woman refrains from and should normally abstain from medications. However, since active IBD disease can be more harmful for baby than side effects of medications, it may be necessary to take medicines in pregnancy.

However, a personalized treatment should be planned through consultation with other physicians, if necessary, and only the necessary medications should be prescribed. Every pregnant woman with IBD should be clearly informed that only 85% of pregnancies are complication-free even for healthy people.

It should be remembered that inflammatory bowel diseases are more harmful for both baby and mother than medication therapy, if it is not treated properly. Briefly, medication therapy should be prescribed for pregnant women, only if absolutely necessary.

Should Patients with Inflammatory Bowel Disease Stop Medication Treatment in Pregnancy?

It is recommended to stop certain drugs that suppress the immune system, such as azathioprine (Imuran) and 6-mercaptopurine, 3 months before planned pregnancy. If patients have concerns about exacerbation of disease after cessation of such medicines, primary physician of the patient should be contacted to weigh risks against benefits before making a decision on whether the medications are stopped or not; moreover, a patient who takes one of these medicine may accidentally get pregnancy and in such cases, pregnancy should be supervised very closely.

Up-to-date literature reports that usual doses of various corticosteroid agents commonly used in treatment of inflammatory bowel diseases do not pose an increased risk for baby; if remission is achieved with these medications, it is not necessary to stop them, when a patient with IBD gets pregnant. As it is known that 5-ASA agents do not cause aspirin-independent increase in the risk of bleeding, they are not required to be stopped due to risk of bleeding.

Use of some medications is not recommended in pregnancy and patients are advised to get pregnant at least three months after such drugs are stopped. On the other hand, many pregnant women who took these medications in their pregnancy gave birth to healthy babies and therefore, current evidences do not support a certain indication for termination of pregnancy in mothers who have used these drugs.

Can Patients with Inflammatory Bowel Diseases Use Drugs in Lactation?

It is acknowledged that doses of corticosteroid agents prescribed for treatment of IBD do not increase risk of any fetal anomaly or do not lead to miscarriage. However, it can be theoretically mentioned that use of too high doses of these drugs in last trimester of pregnancy may cause apathy, decreased activity and low corticosteroid levels by suppressing synthesis of corticosteroids in adrenal glands of the newborn infant and therefore, this risk should be notified to the primary physician of the newborn infant.

Physician should be warned and therefore, these newborn infants should be followed up by a specialized physician. As cortisone passes to newborn infant from breast milk, same condition applies to lactation. In both cases, recovery is achieved without any complications after use of cortisone is stopped.

Is It Necessary to Terminate Pregnancy If Mother Has Inflammatory Bowel Disease?

It is required very rarely or never to terminate pregnancy due to documented inflammatory bowel disease in mother. Instead of terminating the pregnancy, inflammatory bowel disease of women should be properly treated and additionally, physicians should start a comprehensive care.

Which Diagnostic Methods of Inflammatory Bowel Disease Can Be Used In Pregnant Women?

Abdominal ultrasound can be scanned both for supervision of pregnancy and for IDS and it is absolutely harmless for mother and baby. Gastroduodenoscopy or colonoscopy (rectoscopy, sigmoidoscopy and even ileo-colonoscopy) can be safely performed in pregnant women, provided it is required or absolutely indicated and performed in 2nd trimester of pregnancy by a specialized physician under mild sedation, if possible.

Potential gains should be carefully weighed against risks in first and last trimesters. However, these methods should be considered when they are absolutely necessary to determine the most appropriate treatment method. Magnetic resonance imaging (MRI) can also be preferred for some cases, which is probably harmless. Diagnostic procedures that require exposure to radiation (tomography, X-rays) should be postponed until birth and they should be considered solely for emergencies.

Are There Any Considerations During Delivery Regarding Inflammatory Bowel Disease?

Spontaneous vaginal delivery is generally preferred for pregnant patients with inflammatory bowel disease. However, caesarean section can be preferred, after a consensus is reached with an obstetrician, if medical history is notable for past abdominal surgeries, fistula in anal region or hips or presence of an ileostomy.

Is There A Diet That Should Be Followed By Pregnant Women with Inflammatory Bowel Disease?

Usually, a specific diet is not necessary for IBD patients who are not pregnant. Undoubtedly, patients are recommended to follow general recommendations for healthy eating. IBD patients should ensure sufficient intake of calorie, vitamins and minerals in pregnancy.